title: Transmission potential of influenza A/H7N9, February to May 2013, China.
abstract: BACKGROUND
  On 31 March 2013, the first human infections with the novel influenza A/H7N9 virus were reported in Eastern China. The outbreak expanded rapidly in geographic scope and size, with a total of 132 laboratory-confirmed cases reported by 3 June 2013, in 10 Chinese provinces and Taiwan. The incidence of A/H7N9 cases has stalled in recent weeks, presumably as a consequence of live bird market closures in the most heavily affected areas. Here we compare the transmission potential of influenza A/H7N9 with that of other emerging pathogens and evaluate the impact of intervention measures in an effort to guide pandemic preparedness.
  
  
  METHODS
  We used a Bayesian approach combined with a SEIR (Susceptible-Exposed-Infectious-Removed) transmission model fitted to daily case data to assess the reproduction number (R) of A/H7N9 by province and to evaluate the impact of live bird market closures in April and May 2013. Simulation studies helped quantify the performance of our approach in the context of an emerging pathogen, where human-to-human transmission is limited and most cases arise from spillover events. We also used alternative approaches to estimate R based on individual-level information on prior exposure and compared the transmission potential of influenza A/H7N9 with that of other recent zoonoses.
  
  
  RESULTS
  Estimates of R for the A/H7N9 outbreak were below the epidemic threshold required for sustained human-to-human transmission and remained near 0.1 throughout the study period, with broad 95% credible intervals by the Bayesian method (0.01 to 0.49). The Bayesian estimation approach was dominated by the prior distribution, however, due to relatively little information contained in the case data. We observe a statistically significant deceleration in growth rate after 6 April 2013, which is consistent with a reduction in A/H7N9 transmission associated with the preemptive closure of live bird markets. Although confidence intervals are broad, the estimated transmission potential of A/H7N9 appears lower than that of recent zoonotic threats, including avian influenza A/H5N1, swine influenza H3N2sw and Nipah virus.
  
  
  CONCLUSIONS
  Although uncertainty remains high in R estimates for H7N9 due to limited epidemiological information, all available evidence points to a low transmission potential. Continued monitoring of the transmission potential of A/H7N9 is critical in the coming months as intervention measures may be relaxed and seasonal factors could promote disease transmission in colder months.
authors.affiliation: Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, 31 Center Dr, MSC 2220, Bethesda 20892-2220, Maryland, USA. gchowell@asu.edu.
authors.forename: Gerardo
authors.initials: G
authors.lastname: Chowell
authors.forename: Lone
authors.initials: L
authors.lastname: Simonsen
authors.forename: Sherry
authors.initials: S
authors.lastname: Towers
authors.forename: Mark A
authors.initials: MA
authors.lastname: Miller
authors.forename: Cécile
authors.initials: C
authors.lastname: Viboud
mesh_terms: D000818:Animals; D001499:Bayes Theorem; D002681:China / Q000453:epidemiology; D004196:Disease Outbreaks; D006801:Humans; D064766:Influenza A Virus, H7N9 Subtype / Q000472:pathogenicity*; D005585:Influenza in Birds / Q000453:epidemiology / Q000635:transmission / Q000821:virology; D007251:Influenza, Human / Q000453:epidemiology / Q000517:prevention & control / Q000635:transmission* / Q000821:virology; D008954:Models, Biological; D011200:Poultry; D013624:Taiwan / Q000453:epidemiology; D015047:Zoonoses / Q000453:epidemiology / Q000635:transmission / Q000821:virology